Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 3119 | AZ |
Y | 207Q00000X | Family Doctor | 3119 | AZ |
NPI | 1073583035 |
---|---|
Provider Name | Dr. Jordan S Ross |
First Address | Gilbert, AZ 85296-6675 |
Second Address | Gilbert, AZ 85296-6675 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2006 |
Last Update Date | 09/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3119 | STATE LICENSE (01) | AZ |
G14744 | (02) | AZ |